ICD-10: M71.112

ICD-10 code M71.112 refers to "Other infective bursitis, left shoulder." This classification falls under the broader category of bursitis, which is an inflammation of the bursa, a small fluid-filled sac that acts as a cushion between bones and soft tissues, such as muscles, tendons, and skin. Bursitis can occur in various locations throughout the body, but this specific code pertains to the left shoulder region.

Clinical Description

Definition

Infective bursitis is characterized by the inflammation of a bursa due to infection, which can be caused by bacteria, viruses, or fungi. The left shoulder's bursa may become infected due to direct trauma, systemic infections, or as a complication of other medical conditions.

Symptoms

Patients with M71.112 may present with the following symptoms:
- Localized Pain: Pain in the left shoulder that may worsen with movement or pressure.
- Swelling: Noticeable swelling in the shoulder area, which may be warm to the touch.
- Redness: The skin over the affected bursa may appear red and inflamed.
- Limited Range of Motion: Difficulty in moving the shoulder due to pain and swelling.
- Fever: In cases of severe infection, systemic symptoms such as fever may be present.

Diagnosis

Diagnosis typically involves:
- Clinical Examination: A thorough physical examination to assess pain, swelling, and range of motion.
- Imaging Studies: X-rays or MRI may be used to rule out other conditions and to visualize the extent of inflammation.
- Laboratory Tests: Blood tests or aspiration of the bursa fluid may be performed to identify the causative organism and determine the appropriate treatment.

Treatment Options

Medical Management

Treatment for infective bursitis often includes:
- Antibiotics: If a bacterial infection is confirmed, appropriate antibiotics will be prescribed.
- Anti-inflammatory Medications: Nonsteroidal anti-inflammatory drugs (NSAIDs) can help reduce pain and inflammation.
- Corticosteroid Injections: In some cases, corticosteroids may be injected into the bursa to alleviate inflammation.

Surgical Intervention

In severe cases where conservative treatment fails, surgical intervention may be necessary to drain the infected bursa or to remove it entirely.

Prognosis

The prognosis for patients with M71.112 is generally favorable with appropriate treatment. Early intervention can lead to a complete resolution of symptoms and restoration of shoulder function. However, if left untreated, infective bursitis can lead to chronic pain and complications.

Conclusion

ICD-10 code M71.112 encapsulates a specific condition that requires prompt diagnosis and treatment to prevent complications. Understanding the clinical presentation, diagnostic approach, and treatment options is crucial for healthcare providers managing patients with this condition. If you suspect infective bursitis, especially in the left shoulder, timely medical evaluation is essential to ensure effective management and recovery.

The ICD-10 code M71.112 refers to "Other infective bursitis, left shoulder." This condition involves inflammation of the bursa, a small fluid-filled sac that acts as a cushion between bones and soft tissues, specifically in the left shoulder. Understanding the clinical presentation, signs, symptoms, and patient characteristics associated with this diagnosis is crucial for effective management and treatment.

Clinical Presentation

Definition and Overview

Infective bursitis occurs when a bursa becomes inflamed due to infection, often resulting from bacteria entering the bursa through a break in the skin or from nearby infections. The left shoulder is a common site for bursitis due to its anatomical structure and the range of motion involved in shoulder activities.

Common Patient Characteristics

• Age: While bursitis can occur at any age, it is more prevalent in adults, particularly those over 40 years old.
• Gender: Males may be more frequently affected than females, although this can vary based on activity levels and occupational hazards.
• Activity Level: Individuals engaged in repetitive overhead activities, such as athletes (e.g., swimmers, baseball players) or manual laborers, are at higher risk.
• Comorbidities: Patients with diabetes, rheumatoid arthritis, or other immunocompromising conditions may be more susceptible to infections, including bursitis.

Signs and Symptoms

Localized Symptoms

• Pain: Patients typically report localized pain in the left shoulder, which may worsen with movement or pressure on the affected area.
• Swelling: There may be noticeable swelling over the shoulder joint, indicating inflammation of the bursa.
• Redness and Warmth: The skin over the affected bursa may appear red and feel warm to the touch, suggesting an inflammatory response.

Functional Impairment

• Limited Range of Motion: Patients often experience restricted movement in the shoulder, making it difficult to perform daily activities such as reaching overhead or lifting objects.
• Weakness: There may be accompanying weakness in the shoulder muscles due to pain and inflammation.

Systemic Symptoms

In cases of severe infection, systemic symptoms may also be present:
- Fever: Patients may develop a fever as the body responds to the infection.
- Chills: Accompanying chills can indicate a more systemic infection.
- Fatigue: Generalized fatigue and malaise may occur due to the body’s inflammatory response.

Diagnosis and Evaluation

Clinical Examination

A thorough physical examination is essential for diagnosing infective bursitis. Healthcare providers will assess the shoulder for tenderness, swelling, and range of motion.

Imaging Studies

• Ultrasound: This can help visualize the bursa and assess for fluid accumulation or signs of infection.
• MRI: In some cases, an MRI may be warranted to evaluate the extent of the inflammation and rule out other shoulder pathologies.

Laboratory Tests

• Blood Tests: Elevated white blood cell counts and inflammatory markers (e.g., C-reactive protein) may indicate an infection.
• Bursa Aspiration: In some cases, fluid may be aspirated from the bursa for analysis to identify the causative organism.

Conclusion

Infective bursitis of the left shoulder (ICD-10 code M71.112) presents with specific clinical features, including localized pain, swelling, and functional impairment. Understanding the patient characteristics and symptoms associated with this condition is vital for timely diagnosis and effective treatment. Management typically involves addressing the underlying infection, which may include antibiotics, anti-inflammatory medications, and physical therapy to restore function and alleviate symptoms. Early intervention can significantly improve outcomes and reduce the risk of complications.

ICD-10 code M71.112 refers specifically to "Other infective bursitis, left shoulder." This code is part of the broader classification of bursitis, which is an inflammation of the bursa, a small fluid-filled sac that acts as a cushion between bones and soft tissues. Below are alternative names and related terms associated with this condition:

Alternative Names

1. Infective Bursitis: A general term that encompasses bursitis caused by infection, which can occur in various locations, including the shoulder.
2. Shoulder Bursitis: While this term may refer to bursitis in general, it can also specify the location when discussing the left shoulder.
3. Left Shoulder Bursitis: A more specific term that indicates the affected area, emphasizing that it is the left shoulder.
4. Subacromial Bursitis: This term may be used if the bursa involved is the subacromial bursa, which is commonly affected in shoulder bursitis cases.
5. Shoulder Joint Infection: This term can be used when discussing infections that may lead to bursitis in the shoulder region.

Related Terms

1. Bursitis: A broader term that refers to inflammation of any bursa in the body, not limited to the shoulder.
2. Infectious Bursitis: This term highlights the infectious nature of the bursitis, distinguishing it from non-infective forms.
3. Acute Bursitis: Refers to a sudden onset of bursitis, which may be infectious in nature.
4. Chronic Bursitis: This term may apply if the bursitis persists over time, potentially leading to recurrent infections.
5. Shoulder Pain: While not specific to bursitis, shoulder pain is a common symptom associated with this condition.

Clinical Context

In clinical practice, understanding these alternative names and related terms is crucial for accurate diagnosis, treatment, and coding. The ICD-10 code M71.112 is essential for billing and coding purposes, ensuring that healthcare providers can effectively communicate the specific condition being treated.

In summary, M71.112 encompasses various terminologies that reflect the nature and location of the condition, aiding in both clinical and administrative contexts.

The ICD-10 code M71.112 refers to "Other infective bursitis, left shoulder." This diagnosis is part of the broader category of bursitis, which is inflammation of the bursa, a small fluid-filled sac that acts as a cushion between bones and soft tissues. Understanding the criteria for diagnosing this condition involves several key components.

Diagnostic Criteria for M71.112

1. Clinical Presentation

• Symptoms: Patients typically present with localized pain, swelling, and tenderness in the left shoulder area. The pain may worsen with movement or pressure on the affected area.
• Physical Examination: A thorough physical examination is essential. The clinician will assess for signs of inflammation, such as warmth, swelling, and restricted range of motion in the shoulder joint.

2. Medical History

• Infection Risk Factors: A detailed medical history should be taken to identify any risk factors for infection, such as recent trauma, surgery, or underlying conditions like diabetes or immunosuppression.
• Previous Episodes: Inquiry about any previous episodes of bursitis or other musculoskeletal issues can provide context for the current condition.

3. Diagnostic Imaging

• Ultrasound or MRI: Imaging studies may be utilized to visualize the bursa and surrounding structures. These modalities can help confirm the presence of fluid accumulation or other abnormalities indicative of bursitis.
• X-rays: While X-rays are not typically used to diagnose bursitis directly, they can help rule out other conditions, such as fractures or arthritis.

4. Laboratory Tests

• Aspiration and Analysis: In cases where infection is suspected, aspiration of the bursa may be performed. The fluid can be analyzed for the presence of bacteria, white blood cells, and crystals, which can help confirm an infectious process.
• Blood Tests: Blood tests may be conducted to check for signs of systemic infection, such as elevated white blood cell counts or inflammatory markers.

5. Differential Diagnosis

• It is crucial to differentiate infective bursitis from other conditions that may present similarly, such as:
  • Non-infective bursitis
  • Rotator cuff injuries
  • Tendonitis
  • Shoulder arthritis

6. ICD-10 Coding Guidelines

• According to the ICD-10 coding guidelines, the diagnosis must be supported by clinical findings and, if applicable, laboratory or imaging results. The specific code M71.112 is used when the bursitis is confirmed to be infective and localized to the left shoulder.

Conclusion

Diagnosing M71.112 involves a comprehensive approach that includes clinical evaluation, medical history, imaging studies, and possibly laboratory tests. The goal is to confirm the presence of infective bursitis while ruling out other potential causes of shoulder pain. Proper diagnosis is essential for effective treatment and management of the condition, which may include antibiotics, anti-inflammatory medications, or in some cases, surgical intervention if the infection is severe or persistent.

When addressing the standard treatment approaches for ICD-10 code M71.112, which refers to "Other infective bursitis, left shoulder," it is essential to understand both the condition itself and the typical management strategies employed in clinical practice.

Understanding Infective Bursitis

Infective bursitis occurs when a bursa, a small fluid-filled sac that reduces friction between tissues, becomes inflamed due to infection. The left shoulder is a common site for this condition, often resulting from bacterial infections, trauma, or underlying health issues. Symptoms typically include pain, swelling, and limited range of motion in the affected shoulder.

Standard Treatment Approaches

1. Initial Assessment and Diagnosis

• Clinical Evaluation: A thorough history and physical examination are crucial. The physician will assess symptoms, range of motion, and any signs of systemic infection (e.g., fever).
• Imaging Studies: X-rays or ultrasound may be utilized to rule out other conditions and assess the extent of the bursitis.

2. Medical Management

• Antibiotic Therapy: If the bursitis is confirmed to be infectious, appropriate antibiotics are prescribed based on culture results or empirical therapy targeting common pathogens, such as Staphylococcus aureus[1].
• Anti-inflammatory Medications: Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen can help reduce pain and inflammation[2].

3. Physical Therapy

• Rehabilitation Exercises: Once the acute infection is managed, physical therapy may be recommended to restore range of motion and strengthen the shoulder muscles. This can include stretching and strengthening exercises tailored to the patient's needs[3].

4. Invasive Procedures

• Aspiration: In cases where there is significant fluid accumulation, aspiration of the bursa may be performed to relieve pressure and obtain fluid for analysis[4].
• Corticosteroid Injections: If inflammation persists after initial treatment, corticosteroid injections may be considered to reduce inflammation and pain[5].

5. Surgical Intervention

• Bursectomy: In chronic or recurrent cases that do not respond to conservative treatment, surgical removal of the bursa may be indicated. This is typically a last resort after other treatments have failed[6].

6. Follow-Up Care

• Monitoring: Regular follow-up appointments are essential to monitor the resolution of symptoms and adjust treatment as necessary. This may include repeat imaging or laboratory tests to ensure the infection is resolving[7].

Conclusion

The management of infective bursitis in the left shoulder (ICD-10 code M71.112) involves a comprehensive approach that includes accurate diagnosis, antibiotic therapy, anti-inflammatory medications, physical therapy, and, if necessary, invasive procedures. Early intervention and appropriate treatment are crucial to prevent complications and promote recovery. If symptoms persist or worsen, further evaluation and alternative treatment options should be considered.

For optimal outcomes, patients should work closely with their healthcare providers to tailor the treatment plan to their specific needs and circumstances.